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Editorials

A tale of two countries: women’s reproductive rights in Ireland and the US

BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2471 (Published 07 June 2018) Cite this as: BMJ 2018;361:k2471

Misrepresentation of facts surrounding Savita Halappanavar's death: who is actually doing it? Not BMJ.

Dear Editors

Although I have no active nor personal interest in the case of Savita Halappanavar (SH)*, I cannot let misleading allegations cloud the key issues surrounding her death.

* I choose to use her initials from here on for easier reading and do not intend any disrespect to her or her loved ones by doing this.

Dr David Jones seems to portray the circumstances of her premature death as simply a missed sepsis diagnosis and the team looking after her could have "instigated early sepsis treatment and performed a legal termination of pregnancy under the current Irish law", since abortion is "legal when the mother's life is at risk" (ref 1).

Using the very same reference material he used, I wished to point out the following facts:

1. The treating doctors and midwives suspected as early as within 6 hours of hospital admission that SH is likely to be experiencing pregnancy loss/miscarriage.

2. SH experienced spontaneous rupture of membranes (SROM) within 15 hours of admission and was informed 8 hours after SROM that it "was unlikely she would continue on to a time of fetal viability"

3. The attending Consultant 1 noted 56 hours after SROM "the patient and her husband were emotional and upset when told that a miscarriage was inevitable". The consultant stated that the patient and her husband enquired about the possibility of using medication to induce miscarriage as they indicated that they did not want a protracted waiting time when the outcome of miscarriage, was inevitable. This was their first (and last known documented) request for termination of pregnancy (TOP).

4. At this time Consultant 1 advised SH and her husband of Irish law in relation to this. At interview the consultant stated “Under Irish law, if there’s no evidence of risk to the life of the mother, our hands are tied so long as there’s a fetal heart”. The consultant stated that if risk to the mother was to increase a termination would have been possible, but that it would be based on actual risk and not a theoretical risk of infection “we can’t predict who is going to get an infection”.

5. Although empirical antibiotics was already started from 21 hours post SROM, there are sufficient clinical signs and observations for the team to actively look for infection at 54 hrs after SROM. There are assertions by the treating team that the patient and her husband were advised (around 56 hrs post SROM) that "if the source of infection could not be found, a termination of the pregnancy might have to be considered"; this discussion was undocumented.

6. Within 6 hours of this (alleged) discussion (62 hrs post SROM), SH's clinical condition rapidly deteriorated requiring intensive monitoring/ intervention, involvement of a Microbiologist and had a spontaneous delivery at 63 hrs post SROM. She was then transferred to HDU/ICU

7. SH died of cardiac arrest some 144 hrs after SROM, despite vigorous measures to treat her condition.

8. The investigation team (when interviewing all involved) did not actually have access to the post mortem results and therefore did not have information about the actual cause of death in this case. Hence, any investigating bias from the post mortem report is minimised.

As reflected in the report, the speed of unfolding events immediately preceding the rapid deteriorating condition of SH was both catastrophic and unexpected, with most of the measures implemented appropriately after the suspicion of sepsis is considered from 56 hrs post SROM. Despite this, the investigating team was highly critical of clinical culture of "await events" in this case.

The possibility of earlier diagnosis (and treatment) of sepsis is always perfect when events are considered in retrospect; any practicing clinician would acknowledge that it is difficult to define a threshold in which the prevailing diagnosis is certain to be sepsis to explain the patient's condition. Another coronial (and subsequently criminal) case involving the death of Jack Adcock illustrates the difficulties in diagnosing sepsis.

Even in retrospect, it would have been less certain when or if early change in antibiotic cover would have changed the ultimate outcome without early TOP.

SH and her husband asked "about the possibility of using medication to induce labour as they indicated that they did not want a protracted waiting time when the outcome was going to be an inevitable miscarriage" AFTER they were told the pregnancy was unlikely to be viable; this suggestion were summarily rejected on the basis that "under Irish law, if there’s no evidence of risk to the life of the mother, our hands are tied so long as there’s a fetal heart" (the consultant's own words) without regard of distress to the mother nor the clinical picture in which the fetus was unlikely to survive.

Even after the referendum, the Irish "government draft legislation indicates that abortion will be available without limitation until 12 weeks’ gestation and after that only with some indication of serious threat to the woman’s health or in cases of fetal anomaly" (ref 3); this would not necessarily alter the outcome of SH's case but is intended to encourage more open dialogue and consideration without resorting to blanket excuses and disincentive measures effectively stonewalling.

To suggest the matter is essentially a delayed diagnosis of sepsis causing SH's death is misleading and mispresents the fundamental issue whereby any discussion of TOP (when obvious that to proceed and persevere with the pregnancy is futile), is rejected outright on the basis of a fetal heart beat without regard for maternal mental and physical wellbeing.

It might be alright for clinicians unwilling to address the moral dilemma of TOP to hide behind the law and passively "await events"; in this case a young woman's life is lost though this medical misadventure dictated by misdirected ideas.

I would not want anyone to take that lesson away from her death through misrepresentation of facts.

We "await events" no more on this matter.

References

1. https://www.bmj.com/content/361/bmj.k2471/rr-1

2. https://www.hse.ie/eng/services/news/nimtreport50278.pdf

3. https://www.bmj.com/content/361/bmj.k2471

Competing interests: No competing interests

24 June 2018
Shyan Goh
Orthopaedic Surgeon
Sydney, Australia